Quitline Services Questionnaire

National Quitline Data Warehouse

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0856 can be found here:

Documents and Forms

Document Name Document Type
Quitline Services Questionnaire Form
Quitline Services Survey G4. NQDW Quitline Services Survey_2 18 2015.docx Form
G2. Advance Email for Services Questionnaire.docx G2 IC Document
G3. Reminder Email for Services Questionnaire.docx G3 IC Document

Information Collection (IC) Details

IC Title:	Quitline Services Questionnaire	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	Quitline Services Survey	G4. NQDW Quitline Services Survey_2 18 2015.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 53	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	212	212
Annual IC Time Burden (Hours)	71	71
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
G2	G2. Advance Email for Services Questionnaire.docx	09/19/2012
G3	G3. Reminder Email for Services Questionnaire.docx	09/19/2012

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.